Substance Abuse Counseling Intake Form
Client Information
Full Name
Date of Birth
Gender
Female
Male
Other
Prefer not to say
Phone Number
Email Address
Home Address
Emergency Contact
Name
Relationship
Phone Number
Presenting Concerns
Describe the main reason(s) for seeking counseling
Substance Use History
List substances used (alcohol, drugs, etc.) and frequency
Duration of use
Date of last use
Prior substance abuse treatment? If yes, please specify
Medical & Mental Health History
Medical conditions
Current medications
History of mental health issues or diagnoses
Support System
Describe your current support system (family, friends, groups, etc.)
Additional Notes
Is there anything else you would like your counselor to know?